Review of Multiple Chemical Sensitivity: Identifying

diagnosis, treatment and Management of Multiple chemical sensitivity

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• 4.1diagnosis and prevalence of mcs
• Studies on the prevalence of MCS in Australia
• Studies on the prevalence of MCS in other countries

4diagnosis, treatment and Management of Multiple chemical sensitivity Difficulties in attempts at establishing diagnostic criteria for MCS are reflected in clinical medical practice. For MCS, clinicians are confronted with a range of self-reported symptoms with which individuals present, differing views on modes of action for MCS, no characteristic diagnostic markers for the disorder and challenges in determining the types and levels of chemical exposures responsible for symptoms. In terms of treatment or management of MCS, the commonly used Consensus Criteria for MCS include the observation of improvement of symptoms upon removal of triggers, but other than for this avoidance strategy, different views on how MCS should be treated and/or managed may arise from different understandings of the mode(s) of action for MCS. Of interest therefore, is how medical practitioners, both at the specialist and general practitioner level, currently respond to individuals who show patterns of chemical sensitivity suggestive of MCS. In order to explore further these questions, the Office of Chemical Safety and Environmental Health (OCSEH) and the National Industrial Chemicals Notification and Assessment Scheme (NICNAS) in 2006 commissioned a survey to identify current gaps in clinical research and education with regards to diagnosis and treatment/management of MCS. The methodology for the survey which formed part of a report into barriers to the clinical diagnosis and management of MCS is detailed in Appendix 1 and findings from the study have been incorporated into this Chapter. 4.1diagnosis and prevalence of mcs The lack of an objective biomarker for MCS is particularly problematic when considering estimates of the prevalence of MCS. Prevalence estimates exist but are generally not comparable across studies that use different case definitions. There are numerous studies (including Australian state health surveys) that have examined the extent to which people report sensitivity to chemicals. However, depending on the type and extent of questioning regarding the nature of their chemical sensitivity, and the extent to which their experiences fulfil available criteria for MCS, it may not clear how many of these individuals would be diagnosed with MCS and not common, well defined sensitivities such as specific allergies. Studies on the prevalence of MCS in Australia In NSW, in a 2002 Department of Health survey of adult health, 24.6% of respondents (from a total of 12,491 individuals) answered “yes” to the question “Do certain chemical odours or smells regularly make them (or their children) feel unwell?” Females were more likely to report sensitivity to chemical odours than males, and older individuals (over 65 -75 years) were less likely to report sensitivity to chemical odours. There were no differences in reporting rates between urban and rural areas (NSW Department of Health, 2002). The survey also requested information on medical diagnoses, with 2.9% answering “yes” to the question “Have you been medically diagnosed with a chemical sensitivity?” Regarding medical diagnoses, there were no significant differences in reporting rates in medical diagnoses between males and females. However, reporting rates were significantly lower for young people (16-24 years). There were no significant differences in reporting rates for diagnosed sensitivity between urban and rural areas. The severity of these health effects and their conformity to the 1999 Consensus Criteria (Section 2.4) are not known. The survey did not find significant variations in the proportion of people reporting either sensitivity to chemical odours or diagnosed chemical sensitivity based on level of socio-economic disadvantage. In South Australia, two surveys were commissioned by the State Health Department (September 2002 and June 2004) to determine the prevalence of MCS and general chemical sensitivity. Combining both surveys, in 4,009 randomly selected adults, 16.4% of respondents reported sensitivity or adverse health effects from exposure to one or more chemicals, and 0.9% reported a medical diagnosis of MCS. Similar to the NSW health survey, more females than males reported a medical diagnosis of MCS and there were no differences in reporting between urban and rural environments (Fitzgerald, 2008). The prevalence of 0.9% from limited surveys of medically diagnosed MCS in Australia is of a similar order to that reported overseas (below). Studies on the prevalence of MCS in other countries MCS is most commonly reported in western industrialised countries despite the worldwide ubiquitous presence of implicated chemicals. On the basis of personal communications with American clinicians, early estimates suggested that 2%–10% of persons in the general population had substantive disruption of their lives because of MCS (Mooser 1987). However, Cullen and colleagues suggested that this range was too high, with only 1.8% of 2759 patients treated at the Yale Occupational and Environmental Medicine Clinic diagnosed with MCS according to the Cullen diagnostic criteria (Cullen, 1987). They concluded that if only 1.8% of patients in clinics qualified for a diagnosis of MCS, then the rate in the general population would be far lower (Cullen et al., 1992). Studies of college student populations revealed that 15%-22% reported feeling moderately or severely ill after exposure to at least three of five common substances (i.e. pesticides, paint, perfume, car exhaust and new carpet) (Bell et al., 1993a, b). Subsequently, the same investigators found that 28% of college students considered themselves to be "especially sensitive to certain chemicals", but the results were dependent on the type of query. Only 9.7% reported illnesses related to chemicals and only 0.2% of college students reported physician-diagnosed MCS (Bell et al., 1996). Bell et al. (1993c) also reported that 17% of a group of retired elderly persons participating in a longitudinal study of osteoporosis reported feeling moderately or severely ill after exposure to at least four of five common substances (pesticides, paint, perfume, car exhaust and new carpet). Overall, 4% of participants in studies of the community elderly reported physician-diagnosed chemical sensitivity (Bell et al., 1994). Kipen et al. (1995) questioned cohorts of patients visiting different medical clinics. Four percent of patients visiting an environmental and occupational health centre, 15% of patients referred to an occupational clinic, 20% of medical clinic patients, 54% of occupational clinic patients diagnosed with asthma and 69% of MCS patients were identified as reporting symptoms attributable to exposure to 23 or more substances. The results of the 1995 California Department of Health Services Risk Factor Survey of 4,046 randomly selected adults showed that 16% of respondents reported themselves as being unusually sensitive to everyday chemicals. Moreover, 6.3% claimed to have doctor-diagnosed environmental illness or MCS, and of these, inexplicably only about half also reported unusual chemical sensitivity, raising questions as to how this figure relates to MCS. Only 0.6% reported an unusual sensitivity to chemicals plus a medically diagnosed chemical sensitivity that restricted their daily activities (Kreutzer et al., 1999). In North Carolina, Meggs et al. (1996) reported that 33% of randomly selected individuals in this state self-reported chemical sensitivity, with symptoms occurring daily in 4%. Amongst a random sample of 1582 individuals from Atlanta, Georgia, Caress and Steinemann (2003) reported hypersensitivity to common chemicals in 12.6% of respondents, with 3.1% claiming a diagnosis of MCS (Caress and Steinemann 2003; 2004). Reid et al. (2001) reported a prevalence of MCS in British war veterans of 0.2%-1.3% amongst cohorts of several thousand respondents from 3 operational theatres. However, only 30% of those who self-reported MCS met the study criteria for MCS, in this case, that used by Simon et al. (1993) requiring a duration of illness of 3 months or more, symptoms reported in at least three organ systems including the central nervous system and reported sensitivity to 4 or more common exposures from a list that included fresh paint, newspapers, perfume, hair spray, and solvent fumes. Amongst Gulf War veterans, MCS was strongly associated with exposure to pesticides (Reid et al., 2001). In other studies, 30%-36% of Gulf War veterans considered themselves unusually sensitive to certain chemicals (Bell et al., 1998; Kipen et al., 1999). In a sample of Gulf War military personnel in Iowa, USA, 3% met study criteria for MCS, with 2% being medically diagnosed with MCS. Deployed military personnel were nearly twice as likely as non-deployed military personnel to report symptoms suggestive of MCS (Black et al., 2000a). A recent systematic review of multi-symptom conditions in war veterans noted that Gulf War veterans were more than 3 times more likely than non-Gulf veterans to report MCS or chronic multi-symptom illnesses. The prevalence of MCS amongst such individuals is reported to be less than 7% (Thomas et al., 2006). Park and Knudson (2007) reported the prevalence of several disorders associated with medically unexplained physical symptoms based on information from 2002 and 2003 Canadian Community Health Surveys. According to the 2003 survey, the prevalence of individuals claiming a medical diagnosis of MCS in Canada was 2.4%, with the rate for females at least twice that for males. Also, along with CFS and FM, the prevalence of MCS was related to socio-economic status, with the likelihood of reports of MCS increased with decreased household incomes. In summary, worldwide, there are only a small number of studies that have reported the prevalence of medically diagnosed MCS. In these, the prevalence of MCS ranges from 0.2% to 4% for populations or selected population subgroups. A number of other studies have reported the prevalence of chemical sensitivity or general reactions to chemicals, but not necessarily MCS. In these studies, the prevalence ranges from 15% to 36%. 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